Provider First Line Business Practice Location Address:
3645 4TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92103-4142
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-291-2980
Provider Business Practice Location Address Fax Number:
619-291-2984
Provider Enumeration Date:
06/13/2005